Aaron Beck, M.D., the father of cognitive-behavioral therapy.
“We are what we are because we have been what we have been, and what is needed for solving the problems of human life and motives is not moral estimates but more knowledge.” – Sigmund Freud

Robotics has already been introduced in the field of surgery. It is surmisable that in the not-so-distant future, a robot alone might complete an operation. But could you imagine a robot in the field of psychiatry or psychotherapy? In many ways, being robotic is the opposite of what makes for good therapy.


Yet, we teach our young psychiatrists and psychotherapists to act like “robots” in diagnosing and administering a “treatment plan,” following so-called “evidence-based” therapy manuals to guide treatment. Their patients may seem to get “better,” but usually not for long. Structured, manualized treatment may work in surgery, but, in my opinion, it has no place in psychiatry.

As a psychoanalyst, I have a theoretical disagreement with psychotherapeutic formulations that seek to maximize structure and direction at the expense of autonomy, introspection, and self-exploration. I have found that this preference is shared by a great number of patients seeking psychotherapy. Most have more of an interest in being understood and understanding themselves than in being told what to do or think.

Yet, many therapists begin their work by applying a psychiatric diagnosis and then selecting a “modality” from their repertoire of distinct psychotherapies. This is akin to a physician identifying a lesion and then selecting from a range of medical procedures to ameliorate it. While this approach might work for the patient with a tumor or aortic aneurysm, it doesn’t fit as neatly for the depressed or traumatized patient struggling with deep feelings of guilt and shame. There is no algorithm, no formula, no manual that can begin to account for the complexities and differences of individual human beings.

At its core, this mode of practicing psychotherapy—giving a diagnosis and then selecting from a preset variety of interventions—represents the medicalization of the art of psychotherapy. Needless to say, most psychotherapy interventions arrived at via this process are directive ones—cognitive, behavioral, cognitive-behavioral, dialectical behavioral, etc. The consequences of this medicalization are numerous and include, most significantly, an emphasis on observable “symptoms” rather than on their idiosyncratic, symbolic meaning. Patients are taught their symptoms are mere manifestations of underlying diseases, discounting them of any meaning or importance.

It is now being shown that these directive approaches to psychotherapy may be less effective than previously believed, and that the time-honored psychoanalytic approach may be more effective for many types of patients (Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017).

What is called psychotherapy, of course, is little more than human conversation bound by certain expectations or promises, the most important being privacy of communication. Attempts to explain psychotherapy as a medical “treatment” using neurobiological terms—for instance, trying to explain how psychotherapy may affect the brain—are needlessly reductionistic and contribute to the progressive medicalization of the field. There is no reason to turn to brain science to justify what we have known for thousands of years: conversation bound by certain rules can be a helpful and worthwhile endeavor.

An ethical psychotherapy seeks to support and expand the patient’s personal freedom and self-determination. The therapist should have no interest in controlling the patient, giving advice, or instructing the patient to behave in any particular way. Since the single defining feature of all mental illness is a loss of a sense of control, psychotherapy should focus on reestablishing and expanding the patient’s autonomy and individual responsibility. This approach was first outlined by the psychiatrist Thomas Szasz in his 1965 book The Ethics of Psychoanalysis, and it represents, perhaps, the most significant contribution to the psychoanalytic literature since Freud.

The problem with manualized, directive psychotherapy is that it does just the opposite. It unnecessarily restricts the autonomy of patients in the name of helping them, and in the process, may be doing more harm than good.

References

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry. Advance online publication.

Szasz, T. S. (1965). The ethics of psychoanalysis: The theory and method of autonomous psychotherapy. New York: Basic Books.